Provider Demographics
NPI:1598003204
Name:DECICCO, CAMMY
Entity Type:Individual
Prefix:
First Name:CAMMY
Middle Name:
Last Name:DECICCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2064 PACIFIC BLVD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11509-1141
Mailing Address - Country:US
Mailing Address - Phone:516-371-6766
Mailing Address - Fax:
Practice Address - Street 1:385 PEARSALL AVE STE 1
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1800
Practice Address - Country:US
Practice Address - Phone:516-371-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist